Social cognitive determinants of drinking in young adults: beyond the alcohol expectancies paradigm

A text message intervention aimed at nurturing peer outreach to help meet drinking limit goals: A remote pilot randomized trial in non-collegiate young adults

OBJECTIVE

Scalable interventions attempting to nurture peer outreach to help young adults meet drinking limit goals remain under-developed. To address this gap, we developed ASPIRE, a text message intervention focused on coaching individuals to engage with close peers to assist them in meeting drinking limit goals.

METHOD

Non-collegiate young adults who had reported one or more heavy drinking days in the preceding month and were at least contemplating change were recruited through social media. Participants were randomly assigned to one of three 6-week text message interventions: Control, Goal Support, or ASPIRE. All groups completed baseline assessments and received weekly text message assessments on Thursdays and Sundays. Control and ASPIRE groups were prompted to complete web-based outcome assessments at 6- and 12-weeks.

RESULTS

We enrolled 92 young adults from 31 US states (65% female; 73% White). All groups had high text response rates but intervention usability was sub-optimal. Follow-up rates were 87% at 6-weeks and 79% at 12-weeks. Compared to Control, ASPIRE participants reported significantly more peer support and less peer pressure to drink. ASPIRE exhibited higher goal confidence compared to the Goal Support group. Using multiple imputation, there were no significant differences in drinking outcomes between groups.

CONCLUSIONS

Preliminary findings from this pilot study suggest that a text message intervention focused on nurturing peer outreach to help meet drinking limit goals holds promise in altering peer support and pressure as well as boosting drinking limit goal confidence. Design improvements are needed to reduce alcohol consumption.

Do current and former cigarette smokers have an attentional bias for e-cigarette cues?

The similarity of e-cigarettes to tobacco cigarettes with regard to shape and usage raises the question of whether e-cigarette cues have the same incentive motivational properties as tobacco cigarette cues. The objective of the present study was to examine whether e-cigarette cues capture and hold smokers' and former smokers' attention and whether the attentional focus is associated with subsequent craving for tobacco cigarettes. It was also examined whether device type (cigalike or mod) moderated this relationship. Participants (46 current daily smokers, 38 former smokers, 48 non-smokers) were randomly assigned to a device type condition in which their eye-movements were assessed while completing a visual probe task. Craving was assessed before and after the task. Smokers, but not former or non-smokers, maintained their gaze longer on e-cigarette than on neutral pictures ( p = 0.004). No difference in dwell time was found between device type. None of the smoking status groups showed faster initial fixations or faster reaction times to e-cigarette compared with neutral cues. Baseline craving was associated with dwell time on e-cigarette cues ( p = 0.004). Longer dwell time on e-cigarette cues was associated with more favorable attitudes towards e-cigarettes. These findings indicate that e-cigarette cues may contribute to craving for tobacco cigarettes and suggest the potential regulation of e-cigarette marketing.

The role of intolerance of uncertainty in terms of alcohol use motives among college students

INTRODUCTION

Hazardous drinking rates among college students are exceedingly high. Despite the link between worry and alcohol use problems, there has been a dearth of empirical work examining worry-related risk factors in terms of motivations for alcohol use. Therefore, the aim of the present investigation was to examine the unique predictive ability of intolerance of uncertainty in terms of alcohol use motives.

METHODS

Participants were 389 college students (72.2% female, Mage=19.92, SD=3.87, Range=18-58 years) who completed self-report measures for course credit.

RESULTS

As hypothesized, after controlling for the effects of gender, smoking status, marijuana use status, alcohol consumption, negative affect, and anxiety sensitivity, greater levels of intolerance of uncertainty were significantly predictive of greater coping (1.5% unique variance) and conformity (4.7% unique variance) drinking motives, but not social or enhancement drinking motives.

CONCLUSIONS

These results suggest that intolerance of uncertainty is associated with drinking to manage or avoid negative emotions, and interventions aimed at reducing intolerance of uncertainty may be helpful in reducing problematic alcohol consumption among college students.

How important are positive and negative outcome expectancies in the treatment of addiction: a narrative review of the literature

Purpose

– The purpose of this paper is to review the substance misuse literature on how outcome expectancies are measured, how they are related with the level of use and other factors as well as their role into treatment and recovery.

Design/methodology/approach

– A narrative review of the literature for all major substances of abuse was undertaken.

Findings

– Existing measurement tools are substance specific. Most research has been in the field of alcohol, and involved students or light and moderate drinkers. Positive expectancies have been found to be related to initiation and level of alcohol, nicotine and cannabis use and also to be modifiable with repeated cue exposure. Negative expectancies have been found to be associated with prevention of smoking, positive changes in drinking and positive effect on treatment outcome for alcohol.

Research limitations/implications

– Both positive and negative outcome expectancies have been found to predict development of substance misuse and recovery from it respectively, but cross-substance comparisons are hindered by lack of appropriate measures.

Originality/value

– The concept of outcome expectancies is present in several theories of addiction. To date there has been no comprehensive review of the extent to which different types of expectancy play a role in different substances and their treatment.

Reducing alcohol-related harm in disadvantaged men: development and feasibility assessment of a brief intervention delivered by mobile telephone

Background

Socially disadvantaged men suffer substantial harm from heavy drinking. Brief alcohol interventions are effective in reducing consumption when delivered via health care. There is a need for tailored brief interventions for disadvantaged men who seldom attend health care.

Objectives

(1) To investigate the best ways to recruit and retain disadvantaged men in a study aimed at reducing the frequency of heavy drinking. (2) To identify the type of content and timing of the delivery that is most likely to engage disadvantaged young to middle-aged men in an intervention delivered by text messages. (3) To determine whether or not the intervention is likely to be an acceptable way to influence the frequency of heavy drinking.

Design

A three-phase study involving the development of the recruitment strategy and the intervention, an assessment of the feasibility of a randomised controlled trial, and a post-study evaluation.

Setting

Community-based study, conducted in Dundee, UK.

Participants

Disadvantaged men aged 25–44 years who had two or more episodes of heavy drinking (≥ 8 units in a single session) in the preceding month. Two recruitment strategies were employed: recruitment through general practice (GP) registers and recruitment through a community outreach strategy.

Interventions

Focus groups explored drinking motives and behaviours of the target group. The intervention also drew on reviews of the literature on: alcohol brief interventions, text message studies, communication theory and behaviour change theories and techniques. The intervention group received 36 text messages with images sent over a 28-day period.

Main outcome measures

The outcome measures evaluated the likely success of a full trial: recruitment of the participants; construction and delivery of a theoretically and empirically based intervention that successfully engages disadvantaged men; potential for the intervention to influence binge drinking.

Results

The focus group analyses identified that personal experience and knowledge of the harmful effects of alcohol was widespread. Furthermore, there was a discrepancy between frequent binge drinking and perceived social expectations and duties. This could usefully be targeted in the intervention. Theoretically and empirically based behaviour change strategies were successfully rendered in attractive, colourful, brief text messages. Both recruitment strategies (GP registers and community outreach) proved successful and a total of 67 men were recruited, exceeding the target of 60. The participants were at high risk of harm because of frequent episodes of heavy binge drinking. Baseline interviews established that those recruited through community outreach drank substantially more and had more frequent binge drinking sessions than those recruited through GP registers. Retention at follow-up was 96%. Extensive process evaluation was conducted. The evaluation showed that 95% of text messages were successfully delivered to participants' telephones. Furthermore, there was a high level of engagement with text messages which sought responses. Most men replied to these texts, often giving carefully structured personal responses. Analyses of the responses indicated a high level of engagement with key components of the behaviour change strategy. Post-trial evaluation showed high levels of satisfaction with the intervention.

Conclusions

This study has shown that disadvantaged men can be recruited and retained in an alcohol intervention trial. A theoretically and empirically based intervention was successfully delivered by text message. Furthermore, the messages were well received and elicited the types of response intended. A full trial of the intervention, incorporating a cost-effectiveness study, should be carried out.

Study registration

This study is registered as ISRCTN10515845.

Funding

The National Institute for Health Research Public Health Research programme.

Underage drinking: prevalence and risk factors associated with drinking experiences among Argentinean children

The aim of this study was to describe the prevalence and predictors of alcohol drinking behavior in children. Data were obtained from 367 children, aged 8-12 years (M = 10.44 years, SD = 1.21 years; 61.9% female) from the city of Córdoba, Argentina. Several scales were used to assess risk factors, including personality traits, alcohol expectancy (i.e., beliefs about the consequences of using alcohol), and perceived peer alcohol use, for alcohol drinking and alcohol drinking experiences. Hierarchical regression analysis was used to determine the contribution of multiple risk factors to the quantity of alcohol consumed. The results showed that 58% of the children had tasted alcohol, and approximately one-third drank alcohol again after the first drinking experience. Twelve-year-old children had a significantly higher prevalence of tasting and drinking alcohol and a significantly greater frequency and quantity of alcohol consumed than younger children. Eighty percent of the children who liked alcohol during their first drinking experience reported that they drank alcohol again. Among the children who did not like alcohol during their first drinking experience, only 31% drank alcohol again. Underage drinking usually occurred under adult supervision in family settings when parents or other relatives allowed them to drink or were aware of their children's drinking. The hierarchical regression analysis showed that being older and male, having more peers that drink alcohol, having higher levels of extroversion, and having alcohol expectancy for social facilitation increased the risk for greater alcohol use. The final model explained 33% of the total variance.

Investigation of Aggravating Psychosocial Factors on Health and Predictability of Smoking and Alcohol Use in Post Adolescent Students

Purpose of this study is to explore those factors which affect the health of students in postadolescent age, focusing on smoking and alcohol use, especially in regard to ways of predicting adoption of this behavior and its frequency to detect future users of tobacco and alcohol use but also high-risk groups, i.e. those people who are led to abuses. On the basis of the research part is the Theory of Planned Behaviour, the axes of which are to be investigated. Specifically, the factors evaluated, except for population parameters, behavioral attitudes, i.e. attitudes towards the behavior of tobacco use and alcohol regulations subjective perceptions and perceptions of control, perceived behavioral control and self-efficacy. Intention is explored to continue or start using tobacco and alcohol in the future and evaluate the behavior. The sample consisted of 138 students of postadolescent age, 18-25 years of both sexes, all of the University of Peloponnese and the Technological Educational Institute of Kalamata, Department of Sparta, Greece. The results of a series of statistical analysis, via SPSS 21.0 statistical program revealed the predictive power of perceived behavioral control and subjective norms to the intention of interpreting 64% of the variance of the latter, of the attitudes toward alcohol in relation to intention that interpret 69% of the variance, of the normative beliefs toward smoking with 69% range of interpretation to the dependent variable, of the perceived behavioral control of smoking with 72% and of the attitudes toward smoking with 77% of interpretation. The results demonstrate the significance and application in universities and technological educational institutes appropriate primary preventive interventions for students nonusers of tobacco and alcohol and appropriate programs of secondary and tertiary prevention in heavy users of tobacco and alcohol use and high-risk individual.

Influence of smoking cues in movies on children's beliefs about smoking

OBJECTIVE

Experimental research has revealed that short exposure to movie smoking affects beliefs about smoking in adolescents. In this study, we tested that association in children.

METHODS

In 2 experiments, participants were exposed to either a cartoon or family-oriented movie and randomly assigned to 20-minute segments with or without smoking characters. Data collection took place at elementary schools. A total of 101 children (8-10 years; 47.5% boys) were exposed to a cartoon, and in a second experiment, 105 children (8-11 years; 56.2% boys) were exposed to a family-oriented movie. Beliefs about smoking (assessed by questionnaire) and implicit associations toward smoking (single target implicit association task) were assessed after watching the movie.

RESULTS

The majority of both samples of children viewed smoking unfavorably. Exposure to movie smoking had no effect on implicit associations toward smoking when experiments were analyzed separately or if the results were combined. For smoking beliefs, effects were again small and only statistically significant for social norms regarding smoking.

CONCLUSIONS

Short-term exposure to smoking in cartoon and family-oriented movies had little immediate impact on beliefs about smoking in preadolescent children, but a significant cumulative impact on norms cannot be ruled out.

Parental smoking and children's attention to smoking cues

Research has shown that children with smoking parents are more likely to initiate smoking than children with non-smoking parents. So far, these effects have been explained through genetic factors, modelling and norm-setting processes. However, it is also possible that parental smoking affects smoking initiation through automatic cognitive processes. Therefore, we examined whether children with a smoking parent focus longer, faster and more often on smoking cues. The children were given two movie clips to watch, during which their attention to smoking cues was assessed with eye-tracking technology. Results showed that children with a smoking parent focused more often and longer on smoking cues compared with children with non-smoking parents. No correlations between attentional bias and explicit smoking cognitions were found. In conclusion, results suggest that parental smoking affects children's attention to smoking cues. These findings may indicate that parental smoking instigates automatic cognitive processes in children who have not experimented with smoking, and possibly even before explicit smoking cognitions become more favourable.

Expectancies and self-efficacy mediate the effects of impulsivity on marijuana use outcomes: an application of the acquired preparedness model

This study tests the acquired preparedness model (APM) to explain associations among trait impulsivity, social learning principles, and marijuana use outcomes in a community sample of female marijuana users. The APM states that individuals with high-risk dispositions are more likely to acquire certain types of learning that, in turn, instigate problematic substance use behaviors. In this study, three domains of psychosocial learning were tested: positive and negative marijuana use expectancies, and marijuana refusal self-efficacy. Participants were 332 community-recruited women aged 18-24 enrolled in a study of motivational interviewing for marijuana use reduction. The present analysis is based on participant self-reports of their impulsivity, marijuana use expectancies, marijuana refusal self-efficacy, marijuana use frequency, marijuana use-related problems, and marijuana dependence. In this sample, impulsivity was significantly associated with marijuana use frequency, marijuana-related problems, and marijuana dependence. Results also indicate that the effect of impulsivity on all three marijuana outcomes was fully mediated by the three principles of psychosocial learning tested in the model, namely, positive and negative marijuana expectancies, and marijuana refusal self-efficacy. These findings lend support to the APM as it relates to marijuana use. In particular, they extend the applicability of the theory to include marijuana refusal self-efficacy, suggesting that, among high-impulsives, those who lack appropriate strategies to resist the temptation to use marijuana are more likely to exhibit more frequent marijuana use and use-related negative consequences.

Development and validation of the Retrospective Alcohol Context Scale

BACKGROUND

Few validated measures exist to capture the context and consequences of specific drinking events among college students.

OBJECTIVES

This study sought to describe the development and validation of the Retrospective Alcohol Context Scale (RACS), a 30-day measure of drinking context among college students.

METHODS

A sample of 169 college students completed daily alcohol assessments for 30 days and completed the RACS at follow-up.

RESULTS

The RACS captured fewer negative consequences than daily assessments; however, high agreement was observed on context variables.

CONCLUSION

Results support the validity of the RACS as a measure of drinking context among college students. The RACS may be most useful when information about drinking needs to be collected under limited time and resources.

SCIENTIFIC SIGNIFICANCE

Further research is needed to examine the RACS among more diverse, probability samples and over longer time periods.

Drinking for negative reinforcement: the semantic priming of alcohol concepts

Cognitive models of alcohol abuse posit that the context typically associated with alcohol use, such as negative affect, implicitly activates alcohol use cognitions, which in turn leads to alcohol consumption. We selected 40 undergraduate women based upon their alcohol use and reported anxiety sensitivity, and proposed that drinking for the purpose of negative reinforcement would predict increased semantic priming between anxiety and alcohol concepts. A lexical decision task compared the response latencies of alcohol targets preceded by anxiety words to those same targets preceded by neutral words (anxiety-alcohol priming). Level of anxiety sensitivity did not relate to anxiety-alcohol priming, but drinking following social conflict was associated with increased anxiety-alcohol priming. This study specifically suggests that the contextual antecedents to drinking behavior relate to the organization of semantic information about alcohol, and more generally supports cognitive models of substance abuse.

Psychological determinants of the intention to educate patients about benzodiazepines

OBJECTIVE

General practitioners and pharmacists do not properly educate their patients about the disadvantages of benzodiazepines. In order to increase and improve education, this study will investigate which psychological factors (i.e., beliefs, outcome expectation, social norm and self-efficacy) predict the intention to educate.

METHODS

A cross-sectional survey study was conducted in which 339 general practitioners and 149 pharmacists in the Netherlands completed a questionnaire.

RESULTS

The Results show that the above-mentioned factors play an important role in forming intentions to educate. However, differences exist between general practitioners and pharmacists.

CONCLUSION

General practitioners and pharmacists intend to educate in cases where they think that benzodiazepines have well-defined disadvantages, when the education they undertake leads to success, when they feel pressure to educate from their surroundings and when they are capable of educating. Implications for practice These findings contribute to a better understanding of patient education and are of great value in developing new interventions to improve education.

A longitudinal test of the theory of planned behavior predicting smoking onset among asthmatic and non-asthmatic adolescents

Despite the particularly detrimental health risks of smoking for adolescent with asthma, several studies demonstrated higher smoking rates among asthmatic adolescents than among healthy adolescents. To gain insight into underlying mechanisms, longitudinal studies on differences in smoking predictors between asthmatic and non-asthmatic adolescents are essential. This longitudinal study with two waves with an 18 months interval tests the Theory of Planned Behavior (TPB) among 346 asthmatic adolescents and 3,733 non-asthmatic adolescents aged 12-16 years. Structural equation models were used to test the predictive value of the TPB in these two groups. The results show, consistent with the TPB, that smoking-related cognitions (attitude, perceived behavioral control, and subjective norm) predict smoking onset via intention among both asthmatic and non-asthmatic adolescents. The TPB predicted smoking onset even stronger among adolescents with asthma. These findings may contribute to the development of tailored interventions for the prevention of smoking among asthmatic adolescents.

The role of adolescent social disinhibition expectancies in moderating the relationship between psychological distress and alcohol use and misuse

We examined the effects of adolescent social disinhibition expectancies and adult psychological distress on alcohol use and misuse in adulthood, using the 1970 British Cohort Study data. Multivariate imputation by chained equations filled in incomplete cases for 7023 men and 6896 women. A propensity to heavy alcohol use and misuse was predicted by social expectations of the releasing effects of alcohol acquired in adolescence (adolescent social disinhibition expectancies). Psychological distress at age 30 increased the likelihood of very heavy alcohol use in men and misuse of alcohol in men and women. An absence of adolescent social disinhibition expectancies protects adults from drinking alcohol. Moreover, among men without these expectancies, psychological distress did not predict heavy alcohol use, whereas this association was present among men with expectations of alcohol. Policies that aim to manage adult alcohol use should be initiated in adolescence. Reduction of psychological distress will prevent both men and women from misusing alcohol.

Cognitive determinants of MDMA use among college students in Southern Taiwan

This study was aimed to examine the Attitudes-Social influence-Efficacy Model for the use of MDMA among college students in Taiwan. A representative sample of 3743 college students participated in this study. Each participant completed a comprehensive survey and 3090 valid data were collected. Correlation analyses displayed that either positive outcome expectancy or social influence was positively related to intention while refusal self-efficacy was negatively associated with intention. Using the Structural Equation Model, the results showed that the model fitted the data well. Intention for using MDMA affected MDMA use. Refusing self-efficacy significantly predicted intention and MDMA use indirectly via intention. Social influence had a direct impact on intention or MDMA use as well as an indirect effect on MDMA use via intention. However, positive outcome expectancy did not have an effect on both intention and the use of MDMA. Our results suggested that preventive programs in colleges for MDMA use should focus on developing strategies in decreasing the social influence and enhancing the refusal self-efficacy.

Young men's ambivalence toward alcohol

There is widespread concern about the health and social consequences of excessive alcohol consumption among young men. Interventions to reduce alcohol-related harm will be affected by ambivalence toward alcohol, because ambivalent attitudes are worse predictors of behaviour than are homogeneous attitudes. It is therefore important to identify aspects of alcohol consumption about which young men are not ambivalent. In-depth interviews were conducted with a socioeconomically diverse sample of 31 men, aged 18-21 living in London, UK. Ambivalence toward alcohol was widespread. None of the drinkers who were interviewed had uncomplicated positive evaluations of drinking: all mentioned compelling reasons not to drink. Most motives for drinking were also identified as reasons for not drinking if consumption became excessive. However, three motives for not drinking were not also motives for drinking: violence, alcoholism, and cost. These findings should be considered during the design of interventions to reduce the health and social consequences of excessive alcohol consumption amongst young men.

Adolescents' beliefs about marijuana use: a comparison of regular users, past users and never/occasional users

A questionnaire investigating adolescents' opinions and experiences regarding marijuana use was administered to 163 adolescents and young adults (96 boys and 67 girls) aged 13 to 20 (mean age = 16.8, s.d. = 1.5). Items referred to marijuana and other substances' dangerousness, representations regarding the positive and negative consequences of marijuana use. Responses were compared according to marijuana use status (classified into never/occasional use, current regular use and past regular use). Results show that adolescents' opinions differ according to their experience with marijuana use. Current regular users evaluate marijuana as less dangerous, but alcohol and heroin as more dangerous in comparison with never/occasional and past users. Current and past users are more likely to define marijuana as a medical drug and a plant used in agriculture, and less likely to define it as an illegal drug. Current and past users evaluate marijuana use as a way to cope with stress, to relax to a greater extent than do never/occasional users do. The latter attribute more negative consequences to marijuana use such as diminished driving ability and school performance and a pathway to hard drugs.

Explaining adolescents' smoking and drinking behavior: the concept of smoker and drinker prototypes in relation to variables of the theory of planned behavior

Research has demonstrated that social image factors play an important role in the course of adolescent's substance use, that is, smoking and drinking. The concept of social images or prototypes is embedded into a theoretical model called the prototype/willingness model. The present study addresses the relative value of the prototype/willingness model in relation to the theory of planned behavior. To study relations between prototypes and adolescents' willingness and intention to engage in smoking and drinking behavior, cross-sectional data among 2814 adolescents (12-16 years) were gathered. Results show that adolescents describe daily-smoking and weekly-drinking peers generally as slightly well adjusted, slightly rebellious, not really cool, and not really attractive. Positive relations were observed between smoker and drinker prototypes and adolescents' intention and willingness to smoke and drink in the future. Furthermore, regression analyses showed that prototypes of daily-smoking and weekly-drinking peers explained a significant part of the variance in intention and willingness to smoke and drink, and added significantly to the variance explained by the variables of the theory of planned behavior.

The Effect of Heavy Drinking on Social Security Old‐Age and Survivors Insurance Contributions and Benefits

This article estimates the effects of heavy alcohol consumption on Social Security Old-Age and Survivor Insurance (OASI) contributions and benefits. The analysis accounts for differential earnings and mortality experiences of individuals with different alcohol consumption patterns and controls for other characteristics, including smoking. Relative to moderate drinkers, heavy drinkers receive fewer OASI benefits relative to their contributions. Ironically, for each cohort of 25-year-olds, eliminating heavy drinking costs the program an additional $3 billion over the cohort's lifetime. Public health campaigns are designed to improve individual health-relevant behaviors and, in the long run, increase longevity. Therefore, if programs for the elderly are structured as longevity-independent defined benefit programs, their success will reward healthier behaviors but increase these programs' outlays and worsen their financial condition.

Areca quid chewing by Taiwanese adolescents: application of the Attitudes Social Influence Self-efficacy (ASE) model

AIMS

To investigate the factors associated with areca quid-chewing behaviour using the Attitudes-Social influence-Self-efficacy (ASE) model as a theoretical framework.

DESIGN

Cross-sectional survey.

SETTING AND PARTICIPANTS

A total of 400 students from a junior high school participated in the study in 2001 in Chia-Yi city (Taiwan).

MEASUREMENTS

Expectancy scales (for the attitude component of the ASE), a self-efficacy scale (for the self-efficacy component of the ASE) and a social norm scale (for the social influence component of the ASE) were utilized. These measures displayed good reliability and validity.

FINDINGS

Forty-seven students (11.75%) reported that they had tried chewing areca quid previously, eight of them practicing chewing it every day. Positive and negative expectancy (r = 0.43, r=- 0.20), self- efficacy (r = - 0.65), and subject social norm (r = 0.53) were significantly correlated with participants' intentions to chew areca quid. In a regression model, self-efficacy (beta = - 0.46, P < 0.001), social norm (beta = 0.22, P < 0.001), positive expectancy (beta = 0.18, P < 0.001) and negative expectancy (beta = - 0.08, P = 0.040) all made independent contributions to predicting intentions to chew and explained 46.8% of the variance in areca quid-chewing behaviour.

CONCLUSIONS

Areca quid chewing appeared to be linked to positive expectancy and social norms pertaining to areca quid chewing associated with adolescents. However, high negative expectancy and high self-efficacy encouraged contrary behaviour. The application of the ASE model as the scenario could improve our understanding of the intention of the areca quid chewing among these adolescents.

Evaluation of drug use prevention programs directed at adolescents

The aim of this article is to present a theoretical model of how to undertake evaluations of prevention programs directed at adolescents. Based on the results from metaanalyses of outcome studies of school-based programs, this article concludes that interactive programs tend to be more effective than not only those mainly intended to increase factual knowledge about tobacco, alcohol, and illegal drugs, but also those initiatives aimed at influencing adolescents' attitudes toward those substances. The interactive strategy corresponds to problem-based learning or the interactive educational approach, now widely popular in educational circles. These outcome studies have provided us with important knowledge. However, there are relatively few evaluation investigations that analyze in substantive detail the process by which adolescents change their alcohol, tobacco, and illegal drug-use behavior, and alter their perceptions about these substances. In an ongoing intervention study based on an interaction framework, involving all youngsters in the ninth grade (15-16 year olds, n = 300, undertaken in year 2001-2002) in the Aland Islands, Finland, the students' perceptions regarding the risks involved in illegal drug use could not be altered. Neither was it possible to decrease the alcohol or tobacco consumption during this school year. However, what did occur was that a number of expectations regarding alcohol were changed, which, in turn, might influence the patterns of alcohol use by the target group. The ways students in the Alands celebrate the end of junior high school are culturally embedded, and this may explain the lack of success in decreasing their alcohol consumption and tobacco use at the end of the ninth grade. Based on the analysis, a combination of outcome and process evaluations is recommended in order to reach a better understanding of how school prevention programs may achieve the desired goals.